Sports Physicals

OverviewNeed and cost

In the US alone, millions of athletes undergo preparticipation evaluations, and millions of healthcare hours are spent on performing these evaluations each year. Because the yield of significant abnormalities in this relatively healthy population is low, the cost-effectiveness of these evaluations has been questioned.[1]

Philosophy

The approach to preparticipation evaluations varies depending on the practitioner and practice situation, as well as on the athlete, his or her level of competition, and the institution and its requirements. At this time, 50 of 51 states (including the District of Columbia) require some form of physical evaluation before participation in sports at the high school level, of which some are legal requirements. Some practitioners approach sports physicals as thorough, periodic health evaluations, whereas others consider these evaluations to be risk-based screening examinations. Neither approach is perfect, and no universal standard exists for what constitutes an adequate or appropriate evaluation for this population.

To complicate matters further, the positional statement of the American Medical Association (AMA) regarding such evaluations is vague and may be interpreted in many ways.[2] According to the AMA, every athlete has the right to a thorough preseason evaluation. Typically, these evaluations are not considered substitutes for thorough medical care, and they are described as screening tools with the purpose of identifying high-risk situations.

Main issues

The main athletic assessment issues can be classified into 3 categories: administrative, coaching/athletic, and medical.

Athletic directors are the ones who usually address the administrative issues, which are often based on institutional policy and on local, state, or national laws. These administrative issues involve liabilities, matters to do with insurers, and the rights of athletes to participate in competitive sports. The administrators rely on the physician to assess athletes for compliance with the relevant administrative codes.

The coaching/athletic issues involve both the coaches and athletes. The athletes want medical clearance so they can safely compete and train. If they have a history of injuries or medical problems, the athletes desire information about how to treat or rehabilitate those conditions to improve their performance and safety. Coaches are interested in fielding a team of healthy athletes. When injuries or illness preclude their athletes from competing, coaches need to know the time period that is required for the injury or illness to heal so they can make decisions about finding capable substitutes. Both athletes and coaches depend on the physician to help them in making these types of decisions.

Medical issues are handled by the physician, athlete, coaching staff, and administrators. The goal is to ensure, as completely and accurately as possible, that an athlete with a specific medical condition can compete safely. Achieving this goal is usually straightforward, but a particular situation can become complicated. Although a number of guidelines are available, many are difficult to interpret or implement. Furthermore, some conditions that affect an athlete's participation in sports do not have clear-cut guidelines. The physician's role is vital in these cases. He or she must not only determine the athlete's safety but also assist team coaches in making decisions about administrative and legal matters.

Goals and objectives

The goals of a preparticipation sports evaluation can be summarized as follows:

Determine that the athlete is in general good health.Assess the athlete's present fitness level.Detect conditions that predispose the athlete to new injuries.Evaluate any existing injuries of the athlete.Assess the size and developmental maturation of the athlete.Detect congenital anomalies that increase the athlete's risk of injury.Detect poor preparticipation conditioning that may put the athlete at increased risk.

For excellent patient education resources, visit eMedicineHealth's Healthy Living Center. Also, see eMedicineHealth's patient education articles Walking for Fitness and Strength Training.

NextTiming, Frequency, and Types of EvaluationsTiming of the evaluation

The timing of an athletic preparticipation evaluation is dependent upon the season of the sport. Many evaluations are performed throughout an entire institution that has teams competing in many sports during various seasons. In this circumstance, one approach is to perform the evaluations before each major season. This approach may be optimal for each sport in its season, but it also requires organization and frequent involvement by the medical team. Another approach is to conduct all physical examinations for the institution at the same time each year. Although this approach is more convenient for the medical team, the evaluations may not be optimally timed for all sports.

The optimal timing for the preparticipation sports evaluation is approximately 6 weeks before the onset of the sports season because this period affords time for the further evaluation of any problems that are discovered, if indicated. If treatable problems are detected, some rehabilitation success can be achieved during those 6 weeks. Furthermore, unconditioned athletes may have an opportunity to improve their conditioning in this time and, thus, hopefully prevent other injuries.

If the physical examination is performed less than 6 weeks before the start of a sports season, some athletes may not have time to recover, become conditioned, or complete a specific evaluation that may necessitate medical clearance for play. As a result, athletes may miss part of the sports season. If the preparticipation evaluation is performed earlier, there is time for other conditions to develop, and the findings of the initial evaluation may no longer be up to date.

Frequency of evaluations

No requirements are established for the frequency of these physical evaluations. Approaches vary from annual evaluations to season-specific examinations to single evaluations performed when an athlete enters a sports program.

High schools typically require annual evaluations before a student's participation. These are usually considered valid for the entire academic season and may diminish the number of evaluations needed by multisport athletes.

Many higher-level institutions use thorough initial evaluations upon the student's admission to its athletic programs, with annual follow-up examinations that are focused on particular items and a review of the athlete's medical history. Some of these follow-up examinations may address only the history if the individual is healthy. If abnormalities are detected on the history screening, these problems are evaluated thoroughly.

In a number of organized professional sports, such as football, preseason and postseason physical examinations are the standard.

Types of evaluations

Two extremes exist in the spectrum of the types of athletic preparticipation evaluations: one by the athlete's personal physician and the other by multiple providers in a multistation setting. Either evaluation is adequate if the proper documentation is completed.

At one end of the spectrum is an evaluation in a private office setting or by the athlete's personal physician. These make up a small percentage of all sports evaluations. The private office examination is ideal from the standpoint of continuity of care. Furthermore, the athlete may feel at ease in the surroundings of a familiar physician. The main drawback to this approach is the difficulty of performing many of these evaluations in the office settings.

At the other end of the spectrum of athletic preparticipation examinations is the multistation evaluation, which involves multiple providers and examination-based specialists. In this approach, a primary care physician may review the patient's history; check his or her vital signs; and examine the abdomen, lungs, and genitals. A cardiologist may then examine the heart, a neurologist performs neurologic testing, a physiatrist assesses the athlete's flexibility, and an orthopedist completes the musculoskeletal evaluation.

This multistation approach requires a coordinated effort of many more personnel. These types of evaluations are often performed in gymnasiums, locker rooms, or auditoriums; thus, privacy for the patient is lost. Multistation evaluation is ideal for large volumes of athletes and provides immediate access to a specialist if abnormalities surface. To achieve patient cooperation, personnel such as coaches may assist in supervising athletes who are waiting to be examined. Trainers and therapists are often used to assess vital signs, evaluate visual acuity, and assess flexibility and range of motion. See Table 1 for common requirements for station-based setup.

Table 1. Requirements for Station-Based Preparticipation Physical Evaluations (Open Table in a new window)

Stations Personnel Required

Sign in

Height and weight

Vital signs

Vision

Physical examination*

Medical history review, assessment, and clearance

Ancillary personnel (coach, nurse, community volunteer)

Ancillary personnel

Ancillary personnel

Ancillary personnel

Physician

Physician

Optional

Nutrition

Dental

Injury evaluation†

Flexibility

Body composition

Strength

Speed, agility, power endurance, balance

Dietitian

Dentist

Physician

Athletic trainer, physical therapist

Athletic trainer, exercise physiologist, physical therapist

Athletic trainer, coach, exercise physiologist, physical therapist

Athletic trainer, coach, exercise physiologist

*The physical examination can be subdivided if more than 1 physician is present. Qualified medical personnel may perform the musculoskeletal examination under the direction of a physician. †A station for the evaluation of musculoskeletal injury may be used to provide a more complete evaluation when a musculoskeletal injury is detected during the required musculoskeletal screening examination.

With the multistation approach, a lead physician should be designated. This physician reviews the results from all the stations and signs the needed forms to clear the athlete for play. The lead physician also checks to ensure that nothing is missed and supplies the appropriate personnel information about athletes who have abnormalities, including those who are still able to compete.

PreviousNextHistory

A thorough medical history is the most fruitful tool in the athletic preparticipation evaluation. When completed and thoroughly reviewed, this history supplies most of the information that is needed to decide if an athlete can safely compete in a given sport.

Many established tools are available to facilitate the collection of key medical information. Much research and thought has gone into the forms that are jointly recommended by the American Osteopathic Academy of Sports Medicine (AOASM), the American Academy of Family Physicians (AAFP), the American Medical Society for Sports Medicine (AMSSM), and the American Orthopaedic Society for Sports Medicine (AOSSM). These forms are easily accessible.

An athlete's medical history should focus on the detection of previous and current disease, previous and current injuries, cardiovascular abnormalities, and musculoskeletal abnormalities. If the athlete's medical history suggests the presence of any of these problems, question him or her for further details, and strongly consider other testing to evaluate these problems.

Key issues that must be addressed in a sports medical history include the following:

Demographic data: Updated information is critical, especially in athletes who are minors. Telephone contact numbers are also essential because the authorization to treat specific conditions may be needed. Tetanus status: With any athletic endeavor, the risk of abrasion and laceration increases as the risk of injury increases. All athletes should be current regarding tetanus immunization. History of excessive weight loss or gain: Changes in weight can indicate eating disorders, steroid abuse, and purging behavior. These disorders are seen not only in female athletes in gymnastics, dance, figure skating, and diving, but also in wrestlers and other athletes. History of anaphylactic reactions: This finding is especially important if an athlete has known anaphylaxis with insect bites. Because many sports take place in an outdoor environment, insect bites are possible. If an athlete has such a history of anaphylaxis, he or she can be advised to always keep an anaphylaxis kit at hand. Furthermore, advance knowledge of an athlete's allergy can alert coaches, trainers, and team physicians to be prepared to treat this life-threatening condition. (See also the Medscape Reference article Anaphylaxis.) Recent and previous concussions: Although the mortality rate associated with head injury in sports is low, more evidence regarding the morbidity associated with repetitive head injuries is emerging.[3] Because athletes, especially those in certain sports, are at risk of head trauma, the athlete's concussion history must be assessed to identify individuals who are at risk and to determine whether they should continue playing contact or collision sports. Dizziness or collapse with exertion: Although this symptom has multiple etiologies, the possibility of heart disease and sudden cardiac death warrants an in-depth evaluation of symptoms, when present. (See also the Medscape Reference article Commotio Cordis.) Family history of exercise-related death: This is a historical finding that puts direct relatives at higher risk for the same condition. Therefore, in cases in which a family history of collapse with exercise is found, the athlete should be evaluated in depth. History of asthma: Because asthma is often triggered by exercise or exertion, the severity of the previous episodes should be evaluated further. In addition, adequate instruction about treatment can help prevent dire consequences from this condition. (See also the Medscape Reference articles Exercise-Induced Asthma [in the Sports Medicine Section] and Asthma [in the Pulmonology section].) Loss or dysfunction in 1 of a pair of organs: If the remaining organ of a pair is injured, entire function can be lost. For the most part, this assessment applies to the eyes, kidneys, and testicles. Menstrual history: An abnormality in menstrual function can be a clue to significant underlying medical conditions, including pregnancy, osteoporosis, nutritional deficits, drug abuse, psychiatric conditions, and eating disorders. (See also the Medscape Reference article Female Athlete Triad.) Use of contact lenses, dental appliances, and other devices: It is important to be aware of the athlete's use of any lenses or devices because they may become dislodged during competition, and some items should not be worn during competition. In addition, athletes may wear jewelry or have body piercings; these should be noted and assessed. Recent or recurrent fractures, dislocations, and other injuries: A history of these types of injuries may indicate a condition that requires further treatment or surgery, or it may indicate an abnormality in the athlete's playing mechanics, style, or equipment. Previous heat illness: This finding is important for certain sports that have peak play seasons during hot seasons and for sports that require the use of heavy restrictive equipment. Individuals with 1 episode of heat illness are at high risk of recurrence. (See also the Medscape Reference article Heatstroke.) Source of the history: Because many athletes are minors, their medical and surgical histories must be obtained with a parent or guardian present. If this is not convenient, history forms could be completed and then sent to a parent or legal guardian for his or her signature. Without the parent's or guardian's involvement, the athlete's history cannot always be considered reliable. PreviousNextPhysical Examination

The physical examination must be global and complete because any abnormality can affect an athlete's sports participation. However, the examination is still somewhat focused on screening for major anomalies. The athletic preparticipation physical evaluation includes a medical examination, an orthopedic examination, and performance testing. However, if the athlete's medical history reveals any problems, those problems should be examined thoroughly and not just for the purposes of screening.

A review of the skills of physical examination is beyond the scope of this article. However, the following is a list of areas that should receive specific attention in an athletic preparticipation evaluation.

Height and weight: These measures indicate growth and development and may reflect general fitness (eg, obesity) and pathology (eg, eating disorders). These measures are also valuable in evaluating an athlete's risks for competing at certain levels. For example, these data may be useful in determining if a thin freshman should play varsity football. A common minimum weight for varsity football participation is 120 lb, although this is not a strict guideline. Furthermore, some sports are classified according to the athlete's size or weight, and these measures may affect the athlete's class. Blood pressure (BP): Although a BP measurement is rarely an indication for disqualification from sports, abnormalities are often first noted during the sports physical examination setting. Athletes with BP changes can be referred for follow-up care with a primary physician. Certain sports may cause significant BP elevations, and this may be a reason to limit an athlete's participation. The BP must be evaluated more than once, and normal BPs for the athlete's age must be considered. Rough guidelines are a BP of 125/80 mm Hg or less for those aged 10-15 years and 130/85 mm Hg for those aged 16 years and older. See Table 2. Visual acuity: Visual acuity does not need to be 20/20 for sports participation, but poor vision can affect the athlete's performance and increase the likelihood of injury. If the athlete's visual acuity is abnormal, interventions can be recommended before his or her participation in sports activities. Some recommendations advocate clearance without intervention for any person with visual acuity of 20/40 or better using both eyes. Skin: Certain sports, such as wrestling, disqualify athletes who have infectious dermatoses, which include impetigo, herpes, and forms of tinea. Other conditions (eg, acne, scabies, nevi) can be detected, and the athlete should be counseled in such cases. Eyes: Pupil reactivity and anisocoria should be noted. Knowledge of preexisting abnormalities can be useful information at a later time in case an athlete has a head injury. Heart: Routine auscultation for murmurs or irregular rhythms is indicated, and auscultation should be obtained with the patient in at least 2 positions (usually sitting and supine), which increase the likelihood of detecting subtle abnormalities. A familiarity with the definitive findings of different valvular lesions is essential. The most common cause of sudden cardiac death in athletes is hypertrophic cardiomyopathy, also known as hypertrophic obstructive cardiomyopathy (HOCM) and Brock disease. The classic murmur in this anomaly is a systolic murmur along the left sternal border, which is accentuated by Valsalva maneuvers and standing; the murmur decreases with handgrip and squat maneuvers. These auscultation examinations can reveal many murmurs, which are mostly benign systolic-flow murmurs, but the examiner must have a trained ear to be able determine the need for further evaluation. Abdomen: The abdominal examination should be conducted to assess organomegaly, especially splenomegaly, because of the risk of rupture in contact sports. Genitalia: The need for a genital examination is an area of controversy among sports medicine physicians. This examination can be used for Tanner staging in adolescents to classify athletes by maturity; thus, developmental delays can be detected. The genital examination can also be used to assess males for the presence of a single testicle and to evaluate for the presence of hernias. Some sports physicians omit the genital examination unless the history indicates a single testicle or inguinal or scrotal swelling; the medical history may be adequate for finding these problems. Furthermore, unless hernias are incarcerated, sports participation may not be prohibited. Musculoskeletal: If the screening history is negative, this evaluation can be quickly completed by using the 90-second orthopedic evaluation as outlined below. Note the general body habitus.Assess the cervical range of motion.Assess shoulder function by having the athlete perform shoulder shrugs, abduction to 90°, and internal and external rotation.Visually inspect the forearms and have the athlete supinate and pronate the forearms with his or her elbows flexed to 90°.Evaluate the hands for rotational deformities by asking the athlete to open and close his or her fists and spread the fingers.Have the athlete perform a duck walk to evaluate function of the hips, knees, and ankles.Assess knee extension and patellar tracking.Ask the athlete to toe walk and heel walk.Ask the athlete to touch his or her toes to check for scoliosis.Performance Testing

Coaches and trainers often perform this test, and the physician may not be needed. The main concern in the performance evaluation is assessing the athlete's flexibility and endurance.

Flexibility can be assessed in many ways. Charts and goniometry may be used to compare ranges of motion on the right and left sides. A simple sit-and-reach test can be used to measure general lower-extremity flexibility. This information is useful in planning exercise programs for specific athletes.

Endurance can be measured with timed tests. One such test is a 12-minute run, during which the athlete's ability to complete the test and the distance covered are measured. Another evaluation is a 1.5-mile run, which is similarly used to assess the athlete's ability to complete the test and the time needed to run the distance.

Other tests may include single maximal weight lifting, timed sprinting, broad jumping, and vertical leaping.

Table 2. Classification of Hypertension by Age Group[4] (Open Table in a new window)

Age Group, y Significant Hypertension,

mm Hg

Severe Hypertension,

mm Hg

Systolic BP Diastolic BP Systolic BP Diastolic BP Children

6-9

10-12

122

126

78

82

130

134

86

90

Adolescents

13-15

15-18

136

142

86

92

144

150

92

98

Source: Report of the Second Task Force on Blood Pressure Control in Children, 1987.[4]

PreviousNextOther Screening Evaluations

The role of other screening evaluations before sports participation has been questioned. For the most part, authorities have recommended against random screening with these tools. Some of these tests are expensive, and some have been evaluated and deemed to have no significant advantage over a thorough medical history and physical evaluation. Also, false-positive findings can lead to unnecessary evaluation and investigation, which can have legal implications that set legal precedents.

One evaluation that has been considered for all athletes is electrocardiography to evaluate cardiac rhythm and cardiac size. Echocardiography is also considered a screening tool for detecting anomalies that may place the athlete at risk for sudden cardiac death. The state of Oregon proposed a protocol approach to help teach providers the most useful screening methods and to collect data over time to help focus future efforts.[5] In time, this effort may shed light on alternative approaches to screening young athletes for life-threatening cardiac anomalies.

A study of 964 athletes found abnormalities in 35% of the echocardiograms — 10% of the total deemed to require an echocardiogram. Ultimately, 0.6% of the athletes had conditions that required disqualifications from activity or further treatment or evaluations beyond echocardiography. The echocardiograms revealed no additional abnormalities when added to history, physical examination, and ECG findings.[6]

Urinalysis had long been part of the sports physical evaluation, but this test eventually proved to yield several false-positive results. At one point, complete blood cell (CBC) counts were measured to evaluate for anemias, which are common among elite athletes; however, the findings are of questionable significance at times.

Orthopedic evaluations often include radiography of the cervical spine, especially among football players. The purpose is to try to detect an athlete's risk for spinal cord injury. Studies show that this kind of screening may not be effective.

Most guidelines for athletic preparticipation evaluations do not include the above tests. Some institutions do require such studies, but these tests are generally not good as screening tools, and they should not be performed in patients with an unremarkable medical history. However, when a risk is evident, a full workup should be performed. For example, some clinicians advocate radiography of the cervical spine in athletes with Down syndrome because these individuals have a higher incidence of congenital instability in the upper cervical spine.

(See also the Medscape Reference article Down Syndrome and the Medscape News articles Part I: Clinical Practice Guidelines With Down Syndrome From Birth to 12 Years and Part II: Clinical Practice Guidelines for Adolescents and Young Adults With Down Syndrome: 12-21 Years.)

PreviousNextClearance for Sports Participation

An athlete should be medically cleared for sports participation only after the medical history and physical evaluation are deemed unremarkable. If the history or physical findings raise concerns, a negative complete workup can help in clearing the athlete for participation. Even then, however, the physician must realize that the athlete is only cleared for a specific sport. Sports with different levels of contact, static activity, and dynamic activity have different criteria for participation clearance. A single athlete may qualify to participate in 1 sport but not in another. Likewise, clearance for participation in 1 sport may not apply to another sport or another level of the same sport.

To help clarify the risks of different sports, the American Academy of Pediatrics (AAP) developed 2 sports classifications based on the level of contact and the level of intensity, as determined by the dynamic and static demands of the sport. Neither classification is all-inclusive, but most of the common sports are included. These range from popular sports, such as football, baseball, hockey, soccer, and basketball, to less common sports, such as skiing, sailing, rodeo, and weight lifting. (Note: Although water sports have their own concerns, the AAP does not consider them a category of sports.)

Contact is divided into 3 categories: contact/collision, limited contact, and noncontact (see Table 3).

Intensity is divided into 2 categories: high to moderate intensity and low intensity. Sports with high to moderate intensity can be subdivided into those with high-dynamic and high-static demands, those with high-dynamic and low-static demands, and those with low-dynamic and high-static demands (see Table 4). Low-intensity sports have low-dynamic and low-static demands; these sports include bowling, cricket, curling, golf, and riflery.

Medical clearance for a sport is easily granted in most cases because the athletes' medical histories and physical findings are often unremarkable. However, when an abnormality is detected, the sport and the severity of the abnormality must be considered together in making a decision about an athlete's participation. The AAP addresses common conditions that arise in athletic preparticipation evaluations and discusses how they are related to clearance for different sports (see Table 5). The physician in charge makes 1 of the following 4 choices[7] :

Unrestricted participation for a particular sport: If an athlete is cleared to participate in a contact sport with high dynamic and static demands, the athlete could potentially qualify to participate in any sport. However, this is not always the case. Clearance with notification of the coach, trainer, and team physician: This choice may be selected for athletes with conditions that allow their participation in a sport; however, these athletes may need special treatment on occasion. A good example is an athlete with mild to moderate and well-controlled, exercise-induced asthma. (See also the Medscape Reference article Exercise-Induced Asthma.) Deferred clearance: This category can be used when suspicious symptoms or signs indicate further workup should be conducted in an athlete, who may eventually be cleared. A good example is an athlete with a newly discovered cardiac murmur that has suspicious characteristics or an individual with a recent concussion and postconcussion syndrome. Disqualification: This category is used when a known condition prohibits an athlete's participation in the given sport. Generally, this decision is not reversible for that particular sport; however, the condition may not preclude the athlete's participation in a sport with a lower safety risk.

Sports are classified by contact level in the table below.

Table 3. Classification of Sports by Contact level (Open Table in a new window)

Contact/Collision Sports Limited-Contact Sports Noncontact Sports Basketball

Boxing*

Diving

Field hockey

Football (flag or tackle)

Ice hockey

Lacrosse

Martial arts

Rodeo

Rugby

Ski jumping

Soccer

Team handball

Water polo

Wrestling

Baseball

Bicycling

Cheerleading

Canoeing/kayaking (white water)

Fencing

Field events (high jump, pole vault)

Floor hockey

Gymnastics

Handball

Horseback riding

Racquetball

Skating (ice, inline, roller)

Skiing (cross-country, downhill, water)

Softball

Squash

Ultimate Frisbee

Volleyball

Windsurfing/surfing

Archery

Badminton

Bodybuilding

Canoeing/kayaking (flat water)

Crew/rowing

Curling

Dancing

Field events (discus, javelin, shot put)

Golf

Orienteering

Power lifting

Race walking

Riflery

Rope jumping

Running

Sailing

Scuba diving

Strength training

Swimming

Table tennis

Tennis

Track

Weight lifting

*Participation not recommended by the AAP.[7] The AAFP, AMSSM, AOASM, and AOSSM have no recommendation against boxing.

Table 4. Sports of High to Moderate Intensity (Open Table in a new window)

Sports With High to Moderate Dynamic and Static Demands Sports With High to Moderate Dynamic and Low Static Demands Sports With Low Dynamic and High to Moderate Static Demands Boxing*

Crew/rowing

Cross-country skiing

Cycling

Downhill skiing

Fencing

Football

Ice hockey

Rugby

Running (sprinting)

Speed skating

Water polo

Wrestling

Badminton

Baseball

Basketball

Field hockey

Lacrosse

Orienteering

Table Tennis

Race walking

Racquetball

Soccer

Squash

Swimming

Tennis

Volleyball

Archery

Auto racing

Diving

Equestrian activities

Field events (jumping)

Field events (throwing)

Gymnastics

Karate or judo

Motorcycling

Rodeo

Sailing

Ski jumping

Water skiing

Weight lifting

*Participation not recommended by the AAP.[7] The AAFP, AMSSM, AOASM, and AOSSM have no stand against boxing.

Table 5. Medical Conditions and Sports Participation[7] (Open Table in a new window)

Condition Explanation Participation Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2)*The athlete needs evaluation to assess the risk of spinal cord injury during sports participation.Qualified yesBleeding disorder*The athlete needs an evaluation.Qualified yesCarditis (inflammation of the heart)Carditis may result in sudden death with exertion.NoHypertension (high BP)Those athletes with significant essential (unexplained) hypertension should avoid weight lifting and power lifting, body building, and strength training. Those with secondary hypertension (hypertension caused by a previously identified disease) or severe essential hypertension need evaluation.†Qualified yesCongenital heart disease (structural heart defects present at birth) Those athletes with mild forms of congenital heart disease may participate fully. Those with moderate or severe forms and those who have undergone surgery need evaluation.‡Qualified yesDysrhythmia (irregular heart rhythm)The athlete needs evaluation because some types of cardiac dysrhythmia require therapy, make certain sports dangerous, or both. Qualified yesMitral valve prolapse (abnormal heart valve Those athletes with symptoms (chest pain, symptoms of possible dysrhythmia) or evidence of mitral regurgitation (leaking) on physical examination need evaluation. All others may participate fully. Qualified yesHeart murmurIf the murmur is innocent (ie, it does not indicate heart disease), full participation is permitted. Otherwise, the athlete needs an evaluation (see Congenital heart disease and Mitral valve prolapse, above). Qualified yesCerebral palsy*The athlete needs an evaluation.Qualified yesDiabetes mellitus*If the diabetes is well controlled, the athlete can play in all sports with proper attention to diet, hydration, and insulin therapy. Particular attention is needed for activities that last 30 minutes or more. YesDiarrhea§Unless the disease is mild, no participation is permitted because diarrhea may increase the risk of dehydration and heat illness. (See Fever, below.) Qualified noAnorexia nervosa, bulimia nervosaPatients need both medical and psychiatric assessments before sports participation.Qualified yesFunctionally 1-eyed athlete, loss of an eye, detached retina, previous eye surgery, or serious eye injuryA functionally 1-eyed athlete has a best-corrected visual acuity (BCVA) of better than 20/40 in the worse eye. These athletes could experience a significant disability if the better eye is seriously injured, as can those athletes with the loss of an eye. Athletes who have previously undergone eye surgery or who have had a serious eye injury may be at increased risk of injury because of weakened eye tissue. Use of eye guards approved by ASTM International (formerly the American Society for Testing and Materials [ASTM]) and other protective equipment may allow the athlete to participate in most sports, but this approach must be judged on an individual basis. Qualified yesFever§Fever can increase cardiopulmonary effort, reduce maximum exercise capacity, make heat illness more likely, and increase orthostatic hypotension during exercise. In rare cases, fever may accompany myocarditis or other infections that may make exercise dangerous. NoHeat illness, history ofBecause of the increased likelihood of the recurrence of heat illness, the athlete needs an individual assessment to determine the presence of predisposing conditions and to arrange a prevention strategy. Qualified yesHuman immunodeficiency virus (HIV) infection§Because of the apparent minimal risk to others, all sports may be played, as allowed by the patient's state of health. In all athletes, skin lesions should be properly covered, and athletic personnel should use universal precautions when handling blood or body fluids with the presence of visible blood. YesKidney, absence of oneThe athlete with 1 kidney needs individual assessment for contact/collision and limited contact sports.Qualified yesLiver, enlargedIf the liver is acutely enlarged, athletic participation should be avoided because of a risk of rupture. If the liver is chronically enlarged, individual assessment is needed before contact/collision or limited contact sports are played. Qualified yesMalignancy*The athlete needs an individual assessment.Qualified yesMusculoskeletal disordersThe athlete needs an individual assessment.Qualified yesHistory of serious head or spine trauma, severe or repeated concussions, or craniotomyThe athlete needs an individual assessment for participation in contact/collision or limited contact sports and also for noncontact sports if deficits in judgment or cognitions are present. Recent research supports a conservative approach to the management of concussions.[3] Qualified yesConvulsive disorder, well controlledThe risk of convulsions during sports participation is minimal.YesConvulsive disorder, poorly controlledThe athlete needs an individual assessment before participation in contact/collision or limited contact sports. Because a convulsion may pose a risk to the athlete or to others, the following noncontact sports should be avoided: archery, riflery, swimming, weight lifting or power lifting, strength training, and sports involving heights. Qualified yesObesityBecause of the risk of heat illness, obese persons need careful acclimatization and hydration.Qualified yesOrgan transplant recipient*The athlete needs an individual assessment.Qualified yesOvary, absence of oneThe risk of severe injury to the remaining ovary is minimal.YesPulmonary compromise, including cystic fibrosis*The athlete needs an individual assessment, but generally, all sports may be played if oxygenation remains satisfactory during a graded exercise test. Patients with cystic fibrosis need acclimatization and good hydration to reduce the risk of heat illness. Qualified noAsthmaWith proper medication and education, only athletes with the most-severe asthma need to modify their participation.YesAcute upper respiratory infectionUpper respiratory obstruction may affect pulmonary function. Athletes, with the exception of those with mild disease, need an individual assessment. (See Fever, above.) Qualified yesSickle cell diseaseThe athlete needs an individual assessment. In general, if the status of the illness permits, the athlete may play all sports except high-exertion, contact/collision sports. Overheating, dehydration, and chilling must be avoided. Qualified yesSickle cell traitIndividuals with the sickle cell trait (AS) are unlikely to have an increased risk of sudden death or other medical problems during athletic participation in most conditions. Exceptions include the most extreme conditions of heat; humidity; and, possibly, increased altitude. Like all athletes, those with the sickle cell trait should be carefully conditioned, acclimatized, and hydrated to reduce any possible risk. YesSkin boils, herpes simplex, impetigo, scabies, molluscum contagiosumDuring the periods in which the patient is contagious, participation in gymnastics with mats, martial arts, wrestling, or other contact/collision or limited-contact sports is not allowed. Herpes simplex virus is probably not transmitted via mats. Qualified yesSpleen, enlarged§Patients with an acutely enlarged spleen should avoid all sports because of the risk of rupture. Those with chronically enlarged spleens need an individual assessment before playing contact/collision or limited-contact sports. Qualified yesTesticle, absent or undescendedAthletes in certain sports may require a protective cup.YesNote: This table is designed to be understood by medical and nonmedical personnel. In the Explanation column, a notation that the athlete needs an evaluation means that a physician with appropriate knowledge and experience should determine whether an athlete with the listed medical condition can safely participate in a given sport. Unless otherwise noted, these evaluations are generally recommended because of variations in the severity of disease and in the risk of injury in specific sports.[7] *Not discussed in text of the AAP source monograph.

†See Table 4 above.

‡Mild, moderate, and severe congenital heart disease are defined elsewhere (26th Bethesda Conference, Med Sci Sports Exerc, 1994).[8]

§See the APP recommendation[7] as indicated for qualifications by other commentators.

PreviousNextDisqualification From Sports Participation and Its Implications

The decision to disqualify an athlete from sports participation is made in light of the specific sport for which the individual seeks medical clearance to participate. When the situation is vague, the guidelines described above (see Clearance for Sports Participation) can help in clinical decision making about granting clearance.

The AAP guidelines[7] are broad and not specific in many areas. If obscure cardiac defects are detected, the current criterion standard for decision making is the 26th Bethesda Conference on cardiac anomalies and participation in sports.[8] Articles by Torg[9, 10] are often referenced, as well as those of Torg et al[11, 12, 13] for cases involving congenital or acquired cervical spinal deformities. Fortunately, obscure conditions that may require such referencing are rare, and usually, a general guideline like that of the AAP is most often used. This resource is valuable because the associated categorizations (contact and intensity) can be used to make recommendations for the athletes that are denied sports participation.

A pitfall to keep in mind is discouraging athletes from general sports participation when they are disqualified from a particular sport; athletes might still be able to compete in other sports and experience the benefits of participation. Furthermore, an optimistic approach is always important when problems are detected in young and impressionable athletes. Many disqualifying conditions can be resolved or controlled with medical or surgical intervention, enabling future sports participation.

In a study by Rifat et al[14] , the authors showed that the great majority of disqualifications as a result of athletic preparticipation evaluations involved the following 7 findings:

Dizziness with exerciseAsthma historyUnfavorable body mass indexSystolic BP elevationVisual acuity defectPresence of a heart murmurMusculoskeletal abnormality

However, many of these conditions were further evaluated and deemed low risk, and clearance was eventually granted to the affected athletes.

Other conditions can be treated with medical intervention, and the athlete may eventually return to the sport. Other athletes can be redirected to different sports in which they can have a good and safe athletic experience.

PreviousNextConclusion

An athletic preparticipation evaluation can be performed efficiently and thoroughly when protocols and tools are in place. Use of a reliable medical history questionnaire and a good screening physical examination are usually adequate to meet these needs. The following issues should always be emphasized:

Demographic data (eg, name, age, sex, sport, telephone numbers, current medications, allergies to medications)History of exercise-induced loss of consciousnessFamily history of sudden cardiac deathHistory of poorly controlled asthmaHistory of recent or previous concussionsHistory of fractures or major musculoskeletal problemsHistory of heat strokeHistory of environmental anaphylactic reactions, as with insect bitesHistory of loss or dysfunction of 1 of a pair of organsHistory of chronic illness requiring regular physician interventionHistory of drastic weight changeFor females only – First menstrual period, menstrual irregularity, last menstrual periodParental signature on history forms for minors

A focused physical examination should emphasize the following:

Vital signs (eg, height, weight, BP)Visual acuityInfectious dermatosesAnisocoriaWheezingHeart murmurs or irregular heart rhythmsAbdominal organomegaly

If abnormalities are detected during the physical examination, further workup should be pursued as indicated.

Finally, the participation status of the athlete for the specific sport should be determined. The main goals of the athletic preparticipation evaluation are as follows:

To discover any abnormalities that places the individual at sport-specific risk of injuryTo inform the athlete of correctible abnormalities before the start of the sport's seasonTo determine the safety of the athlete's participationTo provide a database that team physicians, coaches, and administrators can use for referenceTo provide a platform of interaction between athletes and physicians

Participation in sports is a benefit to which everyone is entitled. Ensuring an athlete's safety can promote a healthy lifelong habit of physical activity in which the athlete can learn about discipline, teamwork, physical fitness, and camaraderie.

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Sports Participation by Paraplegics

Overview

Competitive and recreational sporting opportunities for patients with disabilities have increased tremendously. One particular group of patients that has benefited from these opportunities and now participates in sports in ever-enlarging numbers is individuals with paraplegia. For the purposes of this article, paraplegia is defined as complete or incomplete paralysis in the lower extremities such that a wheelchair must be used as the primary mode of mobility. (See also the articles Spinal Cord Injury: Definition, Epidemiology, Pathophysiology in the Physical Medicine and Rehabilitation section of this site, and Spinal Cord Injuries in the Emergency Medicine section.)

The number of people with paraplegia continues to increase over time as general health and life expectancy has been increased to levels that are comparable to individuals without paraplegia. As a result, the demand by those with paraplegia for competitive and recreational sporting opportunities has exploded. An additional factor for the rapid growth of participation in sporting activities by those with paraplegia is the improvement in accessibility, as well as the improved designs of sporting facilities and wheelchairs, which allow for meaningful athletic competition.

Sports participation is an indispensable method of modern rehabilitation. Especially after medical rehabilitation is completed, sports have an invaluable therapeutic value in renewing the paraplegic's lost powers, helping coordination, and maintaining stamina. Today, individuals with paraplegia participate in all types of sports for competition, enjoyment, and to improve overall fitness.

NextHistory

The demand for competitive wheelchair sports traces its roots back to World War II.[1, 2] Thousands of young veterans returned from the war with physical disabilities; however, the desire to pursue sports was undiminished by these veterans' disabilities. Organized wheelchair sports began with wheelchair basketball. Teams were first formed in Veterans Administration hospitals and then expanded with community-based teams throughout the United States. Today, an extensive professional league, the National Wheelchair Basketball Association (NWBA), continues this tradition.[1] Amateur and professional leagues have formed in other team sports (eg, rugby) and in individual sports (eg, tennis, skiing, track and field).

Olympic-style games for athletes with disabilities were organized for the first time in Rome in 1960.[3] Now called the Paralympics, these games occur every 4 years for persons who fall within 1 of 6 disability groups, including spinal cord injury (SCI). A 2-week event that occurs after the regular Olympics, the Paralympics is run by the International Paralympics Committee (IPC) and has grown into an elite event that attracts nearly 4000 disabled athletes from 136 countries throughout the world.[3]

Overall, the benefits for persons with paraplegia or even tetraplegia to participate in sports activities is as varied as it is significant. Muraki and co-authors "demonstrated that sports activity can improve the psychological status, irrespective of tetraplegics and paraplegics, and that the psychological benefits are emphasized by sports activity at high frequency."[4]

PreviousNextCommonly Participated Sports

Almost any sport in which able-bodied athletes can participate in can be modified to fit participation by individuals with paraplegia. Such common sports include aerobics, air-guns, archery, basketball, bicycling/hand cycling, bowling, canoeing, fishing, football, golf, horseback riding, kayaking, soccer, quad rugby, racquetball, distance racing, rowing, sailing, road racing, skiing, sled hockey, softball, swimming, table tennis, tennis, track and field, trap/skeet shooting, water skiing, weight lifting, wheelchair fencing, and water polo.

PreviousNextSpecific Examples of More Popular SportsWheelchair basketball

The oldest team wheelchair sport is also one of the most physically demanding and one of the most popular. The NWBA nationally organizes wheelchair basketball competitions among 180 teams, which make up 21 conferences. Annual national tournaments are held for male and female divisions, junior divisions, and intercollegiate divisions.[1] The rules are modified from the National Collegiate Athletic Association rules. New wheelchair modifications continue to make the sport more competitive and even fan friendly.

Long-distance cycling/marathons

Fueled by continued technical improvements, road racing has become the most popular form of recreational and competitive activity for individuals with paraplegia. A wheelchair division now exists at almost every major marathon after the first disabled athlete competed at the Boston Marathon in 1975. The participants' racing times continue to improve and amaze. Sports 'n Spokes magazine is a publication that is dedicated to this activity and annually compiles a list of handcycle and bicycle manufacturers.

Quad rugby

Always a hit with new spectators at national wheelchair competitions, rugby is a unique sport for individuals with tetraplegia. The game is played on a basketball court by 4-member teams using a volleyball. Players are classified according to the US Quad Rugby Association (USQRA) classification system. Each class has a point value, and teams are balanced by limiting the number of points on any team to 8. The object is to carry the ball across the other team's goal line. Although the game does not really share similar rules to typical rugby, quad rugby does share a similar spirit and competitiveness. Quad rugby games can also lead to a fair amount of injuries, and the SCI physician can become quite busy during the competition.

Wheelchair tennis

First organized by the National Foundation of Wheelchair Tennis (NFWT) in 1980, the sport of wheelchair tennis is now under the aegis of the US Tennis Association (USTA). The sport follows the rules of the USTA; however, the player in a wheelchair is allowed 2 bounces instead of 1. The professional wheelchair tennis circuit is one of the few wheelchair sports that is largely independent of classification. Although this has increased the popularity of the sport among spectators without SCI, it has limited the success of players with higher-level paraplegia. On a recreational level, wheelchair tennis is one of the few sports where persons with SCI can compete with their able-bodied friends and family members.

Skiing

Also fueled by technologic revolutions, recreational and competitive skiing is extremely popular among those with SCI injuries. Persons with paraplegia and quadriplegia can ski using a sit-ski, mono-ski, or bi-ski. Numerous camps and opportunities for novices to learn and enjoy the sport are available.

Sailing

Another sporting activity that has been made increasingly accessible by continued advances in adaptive equipment is sailing. This activity offers persons with disabilities a feeling of freedom that is unmatched in almost any other sport. The National Ocean Access Project (NOAP) is a leading organization that promotes sailing for people with disabilities. The Shake-A-Leg program in Miami, Florida, operates with the support of the Miami Project to Cure Paralysis, and attracts sailors with disabilities from all over the world to test the latest equipment and train for international sailing competitions.

Fencing

Fencing can be accomplished if the wheelchair is specially modified. A fencing sports wheelchair includes a seat that is mounted to a base. A pedestal underlies the base such that the base is selectively rotatable. There is also a platform that has an upper surface to which the pedestal is affixed, as well as a lower surface. At least 3 wheels are mounted to the platform so that the wheels extend beneath the lower surface of the platform. In addition, there is a lever means for converting single-handed manual motion into forward and backward translation of the platform.

Disabled motorsports

Disabled motorsports include any motorsport that is accessible to the disabled or to wheelchair users, such as those that use motorbikes, quad bikes, go carts, etc. In fact, persons with SCI can participate in anything with an engine.

Other popular wheelchair activities:Water PoloDivingExtreme sports UK four-cross downhill mountain bikingExtreme wheelchair racing and jumping TankChair – An off-road wheelchair that is used for extreme wheelchair sportsParalympic sports

The Paralympics includes 27 sports (20 Paralympic summer sports, 5 Paralympic winter sports, 2 non-Paralympic sports) as follows[3] :

Alpine skiingArcheryAthleticsBiathlonBocciaBowls (non-Paralympic)Cross-country skiingCyclingEquestrianFootball 5-a-SideFootball 7-a-SideGoalballIce sledge hockeyJudoPower liftingRowingSailingShootingSwimmingTable tennisVolleyball (sitting)Wheelchair basketballWheelchair curlingWheelchair dance sport (non-Paralympic)Wheelchair fencingWheelchair rugbyWheelchair tennisPreviousNextParalympics

In 1948, Sir Ludwig Guttmann at the National Spinal Injuries Unit at Stoke Mandeville Hospital in Buckinghamshire, England, introduced the first Stoke Mandeville Games for World War II veterans with SCI.[2, 3] Later, other organizations were formed and sponsored competitions for persons with disabilities. As time went by, multidisability competitions developed and eventually grew into the Paralympics, or "Parallel Games for Athletes with Disabilities."[2]

After 1960, attempts were made to hold every fourth Paralympics in the Olympic host city and were successful in 1960 at Rome and 1964 in Tokyo. However, until 1988, subsequent host cities refused to host the competitions.[2] As the popularity of the Paralympics grew, the IPC was formed to coordinate the Paralympic games and other multidisability competitions on the elite sports level. In 1976, the scope of the Games was widened to accept other disabilities.[2, 3] The Paralympics games have been operating under the IPC since 1994 in Bonn, Germany. In 2000, the summer Paralympics in Sydney consisted of over 4000 athletes from 125 nations competing in 19 events (plus track and field) in both individual and team sports. For the 2004 games in Athens, over 3800 athletes from 136 nations participated.

As with any event of this size, the Paralympics faces significant challenges as it heads into the future. Many of the issues are similar to those found in the regular Olympics, including the use of performance-enhancing substances. The policy of the IPC is that the playing field should be level; unfortunately, 7 Paralympic athletes in the 2004 Athens games were sanctioned for the use of performance-enhancing agents. As a result, the IPC developed the IPC Anti-doping Code in the spirit of fair play to prevent doping in sports for athletes with a disability and in conformity with the general principles developed by the World Anti-doping Agency (WADA), the World Anti-doping Code (WADC).[3]

Another challenge is development; that is, money needs to be raised to keep the Paralympics program going. In November 2004 at the IPC Development Conference, the Paralympic Movement agreed on 5 core areas for development: athlete development, leadership development, organizational development, knowledge development, and global Paralympic development.[3]

Despite these challenges, however, there has been keen excitement regarding the 2012 Paralympic games in London, England. The list of sports and qualification guide is listed at www.paralympic.org.

PreviousNextClassification

An individual who cannot participate or compete in a sport on reasonably equal terms with persons without disabilities because of a functional disadvantage due to permanent disability is eligible for participation in that sport within the IPC program. The classification of athletes was created to equal the playing field within sporting activities in which athletes with disabilities participate. In addition to the classification systems that exist for each injury type (eg, amputation, SCI), unique classification systems exist for each sport. An athlete may be eligible for one sport and not another.

Athletes with SCI have obvious unique functional concerns. The classification of athletes with SCI, while imperfect, tries to take these concerns into account. Athletes in the Paralympics traditionally belong to 1 of 6 different disability groups, divided based on the level of the injury: amputees, persons with cerebral palsy, persons with visual impairment, persons with SCIs, persons with intellectual disability, and a group that includes individuals who do not fit into the aforementioned groups.[5] The first class, for those with cervical injury is subdivided into 3 more classes (A, B, and C) based on upper extremity strength.

The need to change functional classes is consistently reviewed. When an athlete starts competing, he or she is allocated a class that may be reviewed throughout the athlete's career. Individuals are certified in each sport to conduct the process of classification, and these officials are known as classifiers.

Certain sports rate players individually, regardless of diagnosis. For example, wheelchair basketball has a unique system; the 8 different classifications are based on sport-specific tests of shooting, passing, rebounding, pushing, and dribbling abilities, rather than a medical diagnosis or muscle function examination. Higher classification numbers represent greater basketball skills. Athletes are given a numeric point value based on their classification status; the maximum allowable points on the floor is 14.0.

In 2003, the IPC developed a classification strategy with the overall objective to support and coordinate the ongoing development of accurate, reliable, consistent, and credible sport-focused classification systems and their implementation. The IPC Classification Code Version 1.0 is a direct result of recommendations made in this strategy. The results and classification code was published in 2007 and can be found at http://www.paralympic.org/sites/default/files/document/ 120201084329386_2008_2_Classification_Code6.pdf.

The Code is complemented by International Standards that provide the technical and operational requirements for classification. The Code applies to all sports within the Paralympic Movement. Adherence to the International Standards is mandatory for compliance with the Code. The 3 International Standards are as follows:

Athlete evaluation – Procedures for the assessment of athletes and the allocation of sport classProtests and appealsClassifier training and certification

In 2011 the IPC published updated guidelines in skiing. They can be found at http://ipc-alpineskiing.org/Classification/, with 12 classification levels.

Finally, the IPC recently adopted the research paper on “IPC Position Stand – Background and Scientific Rationale for Classification in Paralympic Sport” from Tweedy and Vanlandewijck.[6]

PreviousNextMedical Benefits of Exercise

Multiple studies have found both physical and psychologic benefits from exercise in persons with SCI and that training programs for persons with disabilities can increase maximum oxygen consumption, decrease heart rate at a given work load, increase grip strength, increase arm work capacity, and increase general well-being. However, the amount of studies actually examining these issues is few, and further studies are needed. Please review some of the recent references listed in the References section.

Cardiovascular risk factors

One study showed significant association between cardiovascular risk factors and fitness, similar to that observed in persons without paraplegia.[7] Arm ergometry exercise reduced serum lipids and improved cholesterol ratios as peak oxygen consumption increased. Another study suggested that further benefit to the cholesterol profile was attained if exercise intensity achieved 70-80% of the heart rate reserve.[8]

Strength measures

Common sense would dictate that strength training increases strength and endurance. However, the extent of benefits from a coordinated anaerobic program was not definitively demonstrated until Nash et al published their findings that circuit resistance training over 4 months improved the muscle strength, endurance, and anaerobic power of middle-aged men with paraplegia while significantly reducing their shoulder pain.[9]

Cardiovascular measures

In a 1975 report, Zwiren and Ba-Or demonstrated that athletes in wheelchairs had significantly higher peak oxygen uptake than sedentary individuals in wheelchairs or sedentary individuals without SCI when performing arm exercises.[10] A 1988 study by Davis and Shephard demonstrated that highly active persons with paraplegia showed significantly better cardiovascular responses in multiple measures on cardiac function than inactive persons with paraplegia.[11]

De Groot found improvements in lipid profile, insulin resistance, and other cardiovascular parameters in patients with paraplegia who engaged in exercise.[12]

Psychosocial benefits

Persons with SCI have similar psychosocial ailments as those in persons without SCI but in larger numbers. Depression and feelings of isolation are common. Limited studies have found that exercise in persons with disabilities has led to increased feelings of well-being.[4, 13] Sports and regular activities can also encourage new friendships and help patients develop social support networks. Another study suggested that athletes in wheelchairs are more adventuresome and tough minded than inactive peers. However, whether some of these individuals participated in sports before the injury because they were more tough minded is unclear. In summary, athletes with disabilities seem to gain similar psychologic benefits from sports and exercise as athletes without SCI.

PreviousNextSpecial Medical Risks Associated With Exercise in Individuals With ParaplegiaEpidemiology

It is not entirely clear how many athletes with paraplegia become injured playing sport. One study[14] showed that 24% of all athletes participating in the 2010 Winter Paralympic Games suffered injury. The injury risk was significantly higher than during the 2002 (9.4%) and 2006 (8.4%) Winter Paralympic Games. The authors speculated this increase may have reflected improved data collection systems, but also highlighted a high risk of acute injury in alpine skiing and ice sledge hockey at Paralympic Games.

Specific injury types are discussed below.

Cardiovascular risks

Individuals with paraplegia are reported to have higher resting heart rates and lower stroke volumes while at rest and during exercise than able-bodied individuals. Additionally, persons with thoracic paraplegia have higher resting and exercise catecholamine levels than persons without SCI and persons with cervical SCI. As a result, paraplegic patients reportedly have a degree of excess cardiovascular strain, because a greater percentage of heart rate reserve is required to satisfy a given work level. Whether this translates into any risk of cardiovascular injury is uncertain.

Shoulder and musculoskeletal injuries

Persons with paraplegia depend upon the upper extremities for mobility and transfer. As a result, upper-extremity pain is the most common reported physical injury in persons with SCI, and the shoulder is commonly the most painful joint because it is often the end-bearer of weight and is subjected to significant repetitive strain. Rotator cuff tendinitis, frank tears, and general impingement syndrome are the most common shoulder injuries. Many practitioners believe shoulder pain is worsened in persons with paraplegia by muscle imbalances because overly strong anterior chest and arm muscles overpower the weak posterior scapular and cervical stabilizers. Training programs that emphasize strengthening these weak stabilizers and stretching tight anterior muscles have been proposed to reduce shoulder pain and to improve athletic performance. Other upper-extremity problems include carpal tunnel syndrome, wrist tendinitis, and elbow pain.

Autonomic hyperreflexia

Often observed when persons with SCI are exercising under the control of an electrical current, autonomic hyperreflexia (AH) is most dangerous when it goes unrecognized. Usually limited to persons with SCI above the T6 level, AH occurs because the dissociated sympathetic nervous system becomes activated and is not subject to inhibitory mechanisms. Sympathetic activity is usually initiated by an offending stimulus (eg, kinked Foley catheter). If the offending stimulus is not found, blood pressure can elevate to malignant, life-threatening levels. Some racers in wheelchairs actually induce AH as an ergonomic aid for racing, but this practice is discouraged by physicians.

Fractures

Most athletes with SCIs develop lower-extremity osteoporosis as a result of disuse, immobility, and other factors; these individuals are at higher risk for lower-extremity long-bone (eg, femur, tibia) fractures after simple falls and minor injuries. Aggressive team sports (eg, rugby, basketball) create special risks for fracture injuries. Most lower-extremity fractures in patients with paraplegia have historically been treated nonoperatively; however, in wheelchair athletes, this policy needs to be revisited because operative care might lead to a quicker return to the playing field, with better outcomes and sports achievement.

Overuse injuries

Quite common among athletes with paraplegia, such overuse can cause chronic pain syndromes. These include upper extremities tendonitis, bursitis, and skin maceration and breakdown. Cross-training, proper equipment, and proper training are all elements that lead to preventing these injuries or limiting them to some degree.

PreviousNextSpecial Topics

Wheelchair athletes require specific wheelchairs that allow for maximum function or speed. Typical measurements or design requirements that are established for the sports wheelchair include:

Removable anti-tippersAdjustable tension backrest24" wheelsAdjustable seat dumpVariable camber4" castersFore-aft axle positionRemovable bumpersHeight-adjustable footrest4 wheelsSingle anti-tipper (pivot)16" seat width and backrest heightNylon upholstery

Interestingly, Authier and co-authors published a method of sports wheelchair fabrication that costs less than USD $125 without the wheels.[15] It is these authors' hope that the publication of their design will lead to the spread of sports wheelchairs for the poor in less-developed nations.

Previous, Sports Participation by Paraplegics

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Ankle Fracture in Sports Medicine

EpidemiologyFrequencyUnited States

The ankle joint is the most commonly injured joint in sports.[1] Approximately 70% of basketball players have sprained an ankle, and the likelihood of reinjury is as high as 80%.[2] Lateral ankle sprains account for 90% of all ankle injuries, whereas an ankle fracture occurs only approximately 15% of the time.[3, 4, 5]

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Broken Ankle (Ankle Fracture) and Ankle Sprain.

NextFunctional Anatomy

The distal tibia, distal fibula, and talus bones make up the ankle joint. These 3 bones are bound together by the joint capsule and surrounding ligaments. The anatomic relationship of the tibial plafond (joint surface of the distal tibia) to the talus is important for ankle stability. Because the anterior portion of the talus is more broadly shaped, dorsiflexion increases bone surface contact, thus improving stability. This relationship causes decreased stability during plantarflexion, accounting for the vulnerability to ligamentous injuries when the foot is plantarflexed. See the image below.

Diagram showing the typical locations for ankle fractures occurring from the 4 major injury mechanisms (SA= supination adduction, SE= supination external rotation, PA= pronation abduction, PE= pronation external rotation). Note that the SE fracture is shown as a dashed line, since it is best seen in the lateral projection. PreviousNextSport-Specific Biomechanics

Forces acting on the ankle lead to typical fracture or ligamentous patterns. Determining the position of the ankle during the injury can assist in assessing for ligament stability. Although simple unidirectional forces can be involved in an ankle injury, multidirectional forces are usually involved, making diagnosis a challenge.

Medial complex injuries typically occur from eversion and abduction forces. The medial complex consists of the medial malleolus, the medial facet of the talus, and the superficial and deep components of the deltoid ligament. Eversion of the ankle causes injury to the superficial deltoid ligaments and, if sufficient, the deep deltoid ligament. Avulsion of the distal medial malleolus tends to occur in young and old patients, because the ligamentous strength may be greater than the strength of the bone in these individuals. With continuation of these forces, impaction of the distal lateral malleolus occurs, resulting either in rupture of the syndesmosis or in transverse fracture of the distal fibula.

Most unstable ankle fractures are the result of excessive external rotation of the talus with respect to the tibia. If the foot is supinated at the time of external rotation, an oblique fracture of the fibula ensues. If the foot is pronated at the time of external rotation, a mid- or high-fibular fracture results.

The lateral complex consists of the distal fibula, the lateral facet of the talus, and the lateral collateral ligaments of the ankle and subtalar joints. Lateral malleolus injury (most common type of fracture involving the ankle) typically occurs with supination external rotation forces. The inversion force first strains the lateral ligament complex or avulses (transverse fracture) the lateral malleolus. With continuation of this force, the talus impacts the medial malleolus, causing an oblique fracture of the distal tibia. Inversion ligamentous injuries of the ankle are the most commonly observed soft-tissue trauma in sports.

Posterior malleolus injury typically occurs with a supination-external rotation or a pronation-external rotation injury and represents avulsion of the posterior tibiofibular ligament from the posterior distal tibia.

PreviousProceed to Clinical Presentation , Ankle Fracture in Sports Medicine

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Brachial Plexus Injury in Sports Medicine

Background

Peripheral nerve injuries are not common in noncontact sports. However, in contact and collision sports such as football and rugby, brachial plexus injuries occur often. The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports.[1, 2, 3, 4, 5]

The result of trauma to the brachial plexus can lead to the cervical "stinger" or "burner" syndrome, which is classically characterized by unilateral weakness and a burning sensation that radiates down an upper extremity. The condition may last less than a minute or as long as 2 weeks, with the latter duration described as a chronic burner syndrome.

Recent studies

Bertelli et al reviewed the sensory losses and pain symptoms of 150 patients with brachial plexus lesions that were evaluated and operated on. Sensory losses were believed to be documented on the basis of dermatomal root distribution and pain symptoms were believed to be attributed to lower root avulsion. Prior to surgery, patients underwent clinical evaluation and CT myelo scanning with intradural contrast. Hand and finger sensation were evaluated preoperatively; upper root lesions showed hand sensation was preserved. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. C8 and T1 injuries always were avulsed from the cord. This indicated an overlapping of the dermatomes, which was not as widely reported. Hand sensation was largely preserved in patients with partial injuries particularly on the brachial side.[6]

Sulaiman et al reviewed the clinical outcomes in patients who underwent nerve transfer operations for brachial plexus reconstruction at Louisiana State University over a 10-year period, evaluating recovery of elbow flexion and shoulder abduction. The authors found that nerve transfers for repair of brachial plexus injuries resulted in excellent recovery of both elbow and shoulder functions. They also noted that patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.[7]

Terzis and Barmpitsioti studied the use of wrist fusion in patients with brachial plexus injuries with multiple root avulsions resulting in wrist instability, imbalance, and inability to control the placement of the hand in space. Of 35 patients who underwent wrist fusion and answered questionnaires about their overall perceptions, 97.14% were satisfied with wrist stability and 88.57% reported that the procedure enhanced the overall upper limb function. The Disabilities of the Arm, Shoulder and Hand score was 59.14 +/- 12.9, reflecting moderate ability in daily activities. According to the authors, wrist fusion in patients with brachial plexus palsy is recommended as a complementary procedure, offering a stable, painless carpus, with improvement of overall upper limb function and appearance.7

NextEpidemiologyFrequencyUnited States

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes. True rate of brachial plexus injuries is difficult to determine due to significant underreporting. Many stingers last briefly, and players do not seek medical attention. Clancy et al reported that 33 of 67 college football players (49%) sustained at least 1 burner during collegiate play.[8] Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries.[9] In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries.[10] Traumatic brachial plexus injuries can occur in 0.1% of pediatric patients who have experienced multitrauma.[11]

International

True measure of international occurrence of brachial plexus injuries is undetermined due to significant underreporting in athletes and lack of studies in rugby and hockey involving brachial plexus injuries.

PreviousNextFunctional Anatomy

Injuries to the cervical spine are common. The common level of injury is at C5-C6. Damage to other areas of the spinal area can lead to an array of motor and sensory deficits. The following is a list of cervical nerve roots with the associated area of potential motor and sensory deficits:

C4 - Trapezius; shoulder; top of shouldersC5 - Deltoid, rotator cuff; shoulder abduction; lateral upper arm or distal radiusC6 - Biceps, rotator cuff; elbow flexion; lateral forearm and thumbC7 - Triceps; elbow extension; index and middle finger tipsC8 - Extension of fingers; distal thumb; fourth and fifth fingersPreviousNextSport Specific Biomechanics

The following 3 mechanisms are common to brachial plexus injury:

Traction caused by lateral flexion of the neck away from the involved side (similar to the mechanism in birth trauma)Direct impact to the Erb point causing compression to the brachial plexus (often associated with poor-fitting shoulder pads)Nerve compression caused by neck hyperextension and ipsilateral rotation (The neural foramen narrows in this mechanism.)PreviousProceed to Clinical Presentation , Brachial Plexus Injury in Sports Medicine

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Cervical Spine Acute Bony Injuries in Sports Medicine

Background

Cervical spine fractures lead to substantial morbidity and mortality. Neck injury in athletes can quickly end or change the future of an athlete. Failure to properly recognize and provide early care in cervical spine fracture cases may lead to devastating complications.[1, 2, 3, 4]

A C3 spinous fracture is depicted in the image below.

Lateral view of a C3 spinous fracture.

For patient education resources, see the Back, Ribs, Neck, and Head Center, as well as Neck Strain, Vertebral Compression Fracture, and Whiplash.

NextEpidemiologyFrequencyUnited States

The incidence of all spinal injuries in the United States has been reported at approximately 10,000 cases per year. Nearly 200,000 people in the United States have a history of spinal injuries. These statistics do not differentiate between injuries with fracture and injuries without fracture.[5, 6, 7]

Sports-related activities represent 10-15% of these injuries, and spinal injuries represent 2-3% of all sports-related injuries. Certain sports (eg, American football, diving, gymnastics, skiing, wrestling, rugby, hang gliding, surfing, equestrian events) are more frequently associated with the risk of spinal trauma.[2, 3, 4, 6, 7, 8, 9, 10, 11, 12]

The most common spinal injuries cited in the literature are injuries secondary to contact sports such as football. Nearly 1.2 million high school athletes and 200,000 college and professional athletes participate in football. The National Football Head and Neck Injury Registry contains data on cervical spine injuries as a result of participation in football. A trend can be seen over time, as equipment and helmets improved. The incidence of cervical spine injuries increased until 1976. In that year, antispearing rules were established to prevent the athlete from using the helmet as driving force in tackles. Direct collision created higher axial loads than the neck could withstand, leading to high injury rates. This rule, along with better coaching of blocking and tackling techniques, has resulted in a significant decrease in the number of spinal injuries.[10]

Diving is often cited as another significant cause of cervical spine injuries. Injuries resulting from diving are often associated with devastating outcomes. Diving rules (eg, depth of starting areas) and proper technique have lowered the probability of injury during supervised athletic events. However, unsupervised swimming and diving into shallow water present significant risks. Public awareness of this problem has led to the development of special awareness programs, but the risk of injury remains high.

PreviousNextFunctional Anatomy

The human spine serves to provide structural support and bony protection of the spinal cord. The cervical spine consists of 7 bony vertebrae separated by flexible intervertebral discs. They are joined together by an intricate network of ligaments, which helps form the normal lordotic curve of the cervical neck.[13]

The spinal column can be divided into 2 separate columns based on function and injury patterns. The anterior column consists of the bodies of the vertebrae, intervertebral discs, and the anterior and posterior longitudinal ligaments. The function of the vertebral body is to support weight. The posterior column contains the spinal canal and consists of the pedicles, laminae, articulating facets, and transverse and spinous processes. These structures form the vertebral arch, which encloses the vertebral foramen and protects the neural tissues.

The arch is formed by bilateral pedicles that are oriented posteriorly and join 2 laminae. The spinous process arises posteriorly from the vertebral arch. The cervical transverse processes and 4 articular processes also arise from the arch. The cervical transverse processes are unique to the vertebral column with an oval foramen transversarium. The vertebral arteries pass through these foramina. The posterior column also includes a group of ligaments including the supraspinous, infraspinous, interspinous, and nuchal ligaments.

The first 2 cervical vertebrae are atypical in form and function. The next 5 vertebrae are all similar in structure and function. The atlas, C1, is a ring-shaped bone that supports the skull. Two concave, superior articular facets articulate with the occipital condyles. The atlas does not have a body or spinous process. The atlas has an anterior and posterior arch, each with a tubercle and lateral mass. The axis, C2, is the strongest cervical vertebrae. The atlas rotates on 2 large articulating surfaces. The odontoid process (dens) projects superiorly from the C2 body and is the bony structure that the atlas rotates on. The odontoid process is held in place by the transverse ligament of the atlas.

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Contact sports, falls, and diving in sports may lead to vertebral stress and fractures. Sports that involving tackling can increase exposure to mechanisms causing fractures.

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